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Psychosocial aspects of cardiac rehabilitation

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Title: Psychosocial aspects of cardiac rehabilitation


1
Psychosocial aspects of cardiac
rehabilitation Professor Robert J Lewin
2
Psychological challenges for CHD patients
Frightening, life threatening event (MI, major
surgery) A chronic illness, reduced life
expectancy, symptoms Altered identity - an
invalid, walking time bomb Fears for family and
partner being left alone Threat to employment and
financial status Medication side effects
(lethargy, impotence) Being treated differently
by other people Neurological impairement (esp.
cardiac arrest pats.) Making lifestyle changes,
smoking, diet, activity
3
Psychological illness in post-MI patients
4
Psychological reactions
There are no rules - every patient is
different You cannot look at a patient and know
anything about them You must assess every patient
for anxiety depression health related quality
of life But ………..
5
Generalisation about psychological reactions
30 of patients - life is as good or better than
before MI sex life improved - more intimacy,
strong relationships are improved have an -
active coping style, optimistic personality, low
anxiety, motivated to change, helpful beliefs,
high internal locus of control, higher
confidence (self efficacy), previous good mental
health. The ones who come to rehab! 30 long-term
psychological damage anxious and/or depressed.
Cardiac neurosis poor coping behaviours, high in
misconceptions, little spontaneous recovery
after 6-12 weeks, poor motivation, feel always
at risk of sudden death, previous problems with
anxiety, stress or depression, younger age, no
obvious risk factors, post MI angina
6
Psychological reactions
30 of patients - not the same - reduced
HRQOL Say Im OK but partner says not not
clinically anxious or depressed but - fear of
activity fear of excitement give up enjoyed
hobbies / activities wont travel too far from
home reduce work output - retire early sex
life - not the same or abandoned much quieter
than before - wont argue wont play actively
with grandchildren
7
Assessing presentation in chronic illness
impairment the lesion, the extent of the damage
or disease, e.g. the size of the infarct, the
extent of the blockage of the arteries, the
ejection fraction, etc.
disability the difference from age adjusted
normal, Vo2 Max at exercise testing, report of
angina, activities of daily living, pain, sexual
problems, mobility, depression, anxiety, etc.
handicap the additional imposition of society,
eg. driving licence restrictions, health
insurance, prejudice of employers, access to
sports centres, etc.
International classification of impairments,
disabilities, and handicaps a manual of
classification relating to the consequences of
disease. Geneva World Health Organization,
8
A biomedical model of rehabilitation
After an MI part of the heart muscle is scar
tissue and not pumping blood as well as before
but - the rest of the muscle could be
strengthened to make up for the part that is not
working!! So the impairment will be removed and
the patient will go back to normal! Simple!
9
The relationship of impairment and disability
Impairment causes disability
10
The biomedical model of rehabilitation
by 1975 it was clear that after an exercise
programme many patients could achieve a better
level of fitness than before their heart attack
but many remained disabled and never returned to
a full and active life
psychologists and psychiatrists must get involved
with cardiac rehabilitation
Symposium of the International Society of
Cardiology, Turku, 1975
11
The psychologists questions are ...
12
A biopsychosocial understanding of disability
impairment on its own cannot explain
  • disability
  • the extent of the symptoms reported
  • the success or failure of medical treatment or
    surgery
  • the number of acute medical events and
    readmissions
  • medical costs

to predict all of these you also need to include
  • anxiety depression
  • health beliefs
  • personality
  • patients own attempts to cope
  • social support social class

Lewin, B. 1997, Journal of Psychosomatic Research
43453-462
13
Cardiac misconceptions
Cardiac Misconception Scale (MI patients) any
excitement or shock could cause another heart
attack heart disease is caused by stress
worry or overwork (80) there is a dead part
in my heart that could burst if put under too
much pressure. Havik OE, 1987 Scandinavian
Journal of Psychology, 28281-92.
Angina Misconception Scale angina is a kind
of mini heart attack that damages your heart if
you get angina you should rest as much as
possible it is a good idea to check how you
feel before deciding what to do Furze G,
Journal of Health Psychology 2001 6501-510
14
The importance of beliefs
angina at lower level of activity
deconditioning less efficient use of oxygen in
myocardium
reduce activity to prevent angina further
damage to heart
Lewin, B. 1997, Journal of Psychosomatic Research
43453-462
15
The importance of beliefs
decreasing frequency of angina, higher ischaemic
threshold
development of collateral blood supply to
ischaemic area
Keep active - repeated ischaemic challenge
Lewin, B. 1997, Journal of Psychosomatic Research
43453-462
16
Bad ideas lead to poor coping actions Heart has
been worn out by stress, worry or
overwork Coping action avoid any excitement,
worry or work, to avoid further risk Result a
disabled lifestyle There is a dead part in my
heart that could burst if it were put under too
much pressure coping action - avoid raised heart
rate, breathlessness Result loss of fitness,
lower ischaemic threshold, increased risk of
sudden death Common mistake patients make -
overactivity-rest cycle
17
The over-activity rest cycle
GOOD SPELL
BAD SPELL
GOOD SPELL
GOOD SPELL
BAD SPELL
lower ischaemic threshold
BAD SPELL
ACTIVITY LEVEL
disability less and less related to impairment
TIME
gt anxiety
gt depression
18
What does your angina stop you doing that you
would like to be able to do?
How much can you do even on a bad day?
Do it every day for a week
raised ischaemic threshold
less fear
walking
less depression
Week 2
Week 3
Goal setting and pacing
19
Assessing the risk of disability
Anxiety and depression use validated measure on
all patients (HAD) Low self-perceived health
status ask patient for your age how would
you rate your health if 100 was completely
healthy and 0 was very ill score lower than 80
indicates high risk. Low self efficacy ask
patient, how confident are you you will make a
good recovery? less than 80 higher
risk Beliefs attribution for problem - what
caused your problem? cardiac misconceptions -
use questionnaire
20
Biopsychosocial cardiac rehabilitation
TREATING ANXIETY AND DEPRESSION Give
questionnaire of cardiac misconceptions and
discuss with patient to try to change them to
better understanding Teach relaxation and
stress management Use goal setting and pacing
to get patients back to abandoned pleasurable
activities - (systematic desensitisation) If
anxious or depressed at a clinical level refer to
a clinical psychologist for cognitive therapy,
or, if no psychologist treat with drugs
21
Biopsychosocial cardiac rehabilitation
CHECK AND IMPROVE COPING STRATEGIES bad coping -
resting as a cure for heart disease bad coping
- overactivity-rest cycle bad coping - see how I
feel before I do anything Treatment educate
in better coping Treatment use goal setting and
pacing techniques. Good coping - always do what
I plan to do Good coping - dont let angina
(breathlessness) stop me Good coping - build up
activity as each step becomes easy praise and
encourage these coping strategies
22
Biopsychosocial cardiac rehabilitation
GIVE PATIENT A SENSE OF CONTROL OVER THE ILLNESS
explain lifestyle change, and secondary
prevention, stress ability of patient to get
control over the illness.
BUILD UP PATIENTS SELF EFFICACY set small goals
at 80 confidence level, success increases self
efficacy increases the chance of further success
USE REINFORCERS (rewards) FOR ATTEMPTS AT
COPING patient keeps record of progress, review
it with patient and praise compliance with
programme if appropriate involve family, ask them
to praise coping efforts
23
the Angina Management Programme
explain the overactivity-rest cycle and how to
avoid it teach goal setting and pacing, set goals
every week reward reports of coping and success,
applause from the group group discussions about
cardiac misconceptions, true causes not
myths Discuss how to become more disabled and
how to become less disabled Stress
management relaxation, breathing retraining,
meditation yoga sessions bring in real examples
of recent episodes of stress
Lewin, B. 1997, Journal of Psychosomatic Research
43453-462
24
the Angina Management Programme trial 1
Crossover trial - waiting list to treatment -
82 patients main findings at 1 year after
treatment 30 no angina 70 reduction in
episodes of angina 57 improvement in exercise
duration 72 reduction in self reported
disability (SIP) 50 of patients taken off CABG
list no patient looking for further
treatment Lewin, B, 1995, British Journal of
Cardiology, 2, 219-26
25
The Angina Management Programme trial 2
226 patients randomly allocated to
Depression
Treadmill
Episodes of
Disability
Anxiety
(HAD)
workload
Angina
(SIP)
(HAD)
(METS)
4

2
0
-2

-4

-6
-8

-10

-12
-14
26
The Angina Plan
RCT
home based programme, a patient held manual
trained facilitator 30-60 minutes introduction
session and 4, 10-15 minute phone calls / home
/clinic visits, to set further goals, praise
progress, encourage adherence
Lewin RJP, British Journal of General Practice,
2002, 52, 194-201
27
misconceptions that have to change
Approximately 50 of the improvement in physical
limitations was explained by the change in the
total score on the angina misconceptions scale
significance level
the items in which change predicted
improvement it is very important to avoid
anything that brings on angina 0.03 an attack
of angina does not do you any lasting harm
0.03 if you get angina you should rest as much
as possible 0.03 it is a good idea to check
how you feel before deciding what to do
0.001 my angina was caused by having too much
worry, or stress, or work 0.06 some beliefs
that did not change between groups you should
just ignore angina it is a nuisance nothing more
0.98 it is usually better to carry on even if
you feel a bit under the weather ? 0.27
28
THE END this presentation will be at
www.cardiacrehabilitation.org.uk BHF Care
Education Research Group Department of Health
Sciences Seebohm Rowntree Building University of
York Y010 5DD RJPL1_at_york.ac.uk ? 44 (0)19 04
32 13 27
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